Introduction

1．Nurse and Nursing Education（护士和护理教育）

（1）What is a nurse? （什么是护士？）

A nurse is a person who obtains the nurse practicing certificate after registration, in accordance with the regulations in nursing activities to fulfill the responsibility of protection of life, reduce pain, improve health responsibilities of health professionals. Nurses work in a wide variety of specialties where they may work alone or as a team to assess, analyze, plan, implement and evaluate care.

护士，是指经执业注册取得护士执业证书，依照条例规定从事护理活动，履行保护生命、减轻痛苦、增进健康职责的卫生技术人员。护士的工作范围广泛，在他们所从事的事业中，他们可能单独或作为一个团队来做问诊、分析、计划、实施和评估护理的工作。

（2）Nursing（护理学）

Nursing is a comprehensive application subject under the guidance of natural science and social scientific theory, and it studies preventive health care and is the science of nursing theory and method in the process of disease prevention. With the progress of the society, the rapid development of science and technology, the improvement of people's living standard and the growing demand for the healthcare, nursing has gradually developed from the simple auxiliary medical subject into an independent discipline of the health science.

护理学是一门在自然科学与社会科学理论指导下的综合性应用学科，是研究有关预防保健和疾病防治过程中的护理理论与方法的科学。随着社会的进步、科学技术的迅猛发展和人民生活水平的提高以及健康需求的增加，护理学已经由简单的医学辅助学科逐渐发展成为健康科学中的一门独立的学科。

（3）Nursing Trend（护理的趋势）

With the transformation of medical model and updating health concept, nursing has become a “human-centered” professional; nursing education, from biomedical model to biological, psychological, social patterns; nursing concept, from “disease nursing model” to “centered on people's health” direction; nursing model, from diseases nursing to holistic nursing model. The focus in providing nursing care has shifted from the illness and medical diagnosis to the patient as a total human being with various body functions that can be disrupted or changed due to the illness. The nurse's goal is to help patients return to as “normal” a level of functioning as they can, in the meantime, to adapt to the changes caused by illness. Modern nursing trend is patient-centered care, which is based on patients'physical and mental, social and cultural needs, in accordance with nursing care plan to achieve overall nursing of body and mind, health education and community care. This is also the trend and direction of the development of the nursing in the 21st century.

随着医学模式的转变和健康观念的更新，护理学已经成为“以人为中心”的专业，护理教育从“生物医学”模式转向“生物—心理—社会”模式，护理观念从“以疾病为中心”向“以人的健康为中心”方向转变，护理模式也已从疾病护理模式向整体护理模式转变。护理重点已经从病人的疾病和医疗诊断转向关注患者由于疾病给身体各种功能带来的影响或改变。护士的目标是帮助患者恢复“正常”水平的功能，同时，适应由疾病引起的变化。现代护理趋势是以病人为中心，根据病人身心、社会及文化等需要，按护理计划、护理方案进行身心整体护理、健康教育和社区保健，这亦是21世纪护理发展的趋势和方向。

2．Nursing Process（护理步骤）

Nurses gather information from the patients and other sources, sort the information, plan and organize the nursing care, give the nursing care, and then find out if the care is working. This is done through a system called the nursing process. Nurses in the United States are taught to use an orderly sequence of steps in giving care. These steps—the nursing process—are a way of solving problems or thinking about and planning the care that will be given to the patient （sometimes called the client）. There are five steps in the nursing process: assessing, analyzing, planning, implementing, and evaluating.

护士收集、分类来自病人和其他来源的信息，计划、安排和实施护理，然后检查护理工作是否有效。这些工作是由护理过程系统完成的。美国的护士所接受的护理教育是有序的步骤序列护理。这些步骤或护理过程是解决问题或思考和规划将给予病人（有时也称为客户）的护理的方法。护理过程有五个步骤：问诊、分析、规划、实施和评估。

（1）Assessing（收集资料/问诊）

Assessing is the first step that the nurse gathers information about the patient. The nurse gathers subjective information and objective information. Subjective information is what the patient tells the nurse in the interview about what he/she is feeling, seeing, hearing, or thinking.Objective information is the information the nurse gathers through their senses of vision, hearing, touch, and smell in [a physical examination of the patient]. The information that the nurse gathers in the physical assessment must be recorded as accurately, clearly and completely as possible.

问诊是护士收集病人有关信息的第一步。护士收集主观信息和客观信息。主观信息是病人在问诊中说到的他/她的感觉、视觉、听觉或思维的情况。客观信息是护士给病人体格检查体检时通过自己的视觉、听觉、触觉和嗅觉所收集到的信息。体检的信息必须尽可能准确、清楚和完整地记录下来。

（2）Analyzing（分析）

The second step in the nursing process is analyzing the information gathered in the first step. Analyzing means to analyze the information comprehensively to make conclusions about the condition of the patient. The conclusion made is called the nursing diagnosis. A nursing diagnosis differs from a medical diagnosis. A nursing diagnosis focuses on the patient's response to his /her disease and to the changes it causes in him /her. It deals with the patient's actual problems and probable causes of the problems. Making a nursing diagnosis is not a simple matter. It requires the nurse to identify multiple problems, to gather information continually to change old nursing diagnoses, and to make new nursing diagnoses as the patient's condition changes.

护理过程的第二步是分析问诊中收集到的信息。分析就是综合分析问诊的内容，对病人的病情做出结论。所做的结论称为护理诊断。护理诊断不同于医学诊断。护理诊断是关注病人对疾病所做出的反应以及疾病在身体里的变化。它涉及病人的实际问题和可能引起这些问题的原因。做护理诊断不是一件简单的事。它需要护士发现问题，不断收集信息来改变旧的护理诊断，并在患者的病情发生变化时做出新的护理诊断。

（3）Planning（计划）

The third step in the nursing process is planning. In this step the nurse answers the questions: What is to be done? How is it to be done? When is it to be done? The answers are used to make a nursing care plan. A nursing care plan is one way that nurses communicate about the nursing care with each patient. Each nursing care plan includes：

a.information about the patient, such as name and age；

b.nursing and medical diagnoses；

c.nursing goals and objectives；

d.deadlines for meeting the nursing goals and objectives.

A nursing care plan is revised daily or more often, according to changes in the patient's condition and the type of care he needs as a result. The nursing care plan is used not only for the patient's care while he is in the hospital, but also to plan for his discharge, it is particularly important to involve the members of the patient's family at this planning stage.

护理过程的第三步是规划。在做计划时，护士要回答：准备做什么？怎么做？什么时候做？这些问题的答案就构成一个护理计划。护理计划是护士与每个病人关于护理的一种沟通方式。每项护理计划包括以下内容：

a．患者的信息，如姓名和年龄；

b．护理诊断和医疗诊断；

c．护理目标；

d．达到护理目标的最后期限。

根据病人的病情变化及所需要的护理方式，护理计划每天或者经常都要修改。护理计划不仅用于病人住院期间的护理，也用于出院后的护理。所以在规划阶段就考虑到患者的家庭成员是特别重要的。

（4）Implementing（实施）

In this step, the nurse actually gives nursing care to the patient and implements the nursing care plan. Nursing actions are of three types: dependent nursing actions, independent nursing actions, and interdependent nursing actions. In dependent nursing actions, the nurse carries out the medical orders written by the physician, such as giving medications and performing some treatments. Independent nursing actions are those carried out according to the nursing orders. Interdependent nursing actions are carried out by the nurse in connection with physician orders or in cooperation with other members of the health care team, such as the dietitian.

在这个步骤中，实际上护士就是在做护理病人、实施护理计划的工作。护理工作分为三种类型：依赖护理、独立护理和相互依赖护理。依赖护理是指护士完全根据医嘱进行护理，例如给患者发药和做治疗。独立护理是根据护嘱进行护理。相互依赖护理是指护士结合医嘱或与卫生保健团队的其他成员例如营养师，合作进行的护理工作。

（5）Evaluating（评估）

Evaluating, the last step in the nursing process, means to determine what are successful or valuable. To evaluate the nursing care plan, ask yourself questions such as：

评估是护理过程的最后一步，用于确定什么是成功或有价值的事。在评估护理计划时，问自己这样一些问题，例如：

A. Is the nursing care plan working？

护理计划有作用吗？

B. Is the nursing care helping the patient to develop toward his long-term goals？

护理有助于病人向长期目标发展吗？

C. Is the nursing care helping the patient to reach his short-term objectives in the time given？

护理有助于患者在指定的时间达到短期目标吗？

D. Is the nursing care keeping the patient safe and as comfortable as possible？

护理使病人感到安全、舒适吗？

E. Are nurses using their own and the patient's time and energy in the most efficient way when giving care？

护理时，护士是以最有效的方式使用自己和病人的时间和精力进行护理的吗？

F. Are nurses being careful not to waste supplies and equipment（which could be expensive to patient and hospital or health care agency）？

护士是否小心不浪费医疗用品和器材（对病人和医院或医疗机构来说，这些东西都是昂贵的）？

G. Have the nursing care solved the patient's problems in part or completely？

护理部分或全部解决了患者的问题吗？

H. Have any new patient problems been found since starting to implement the nursing care plan? Were any of these problems a direct result of the nursing care？

开始实施护理计划后，有没有发现患者有新的问题？这些问题是护理导致的直接结果吗？

I. Were any mistakes made in the patient assessment, the nursing diagnosis, nursing orders, or nursing care？

对病人进行的问诊、护理诊断、护嘱，或护理有差错吗？

J. What changes, if any, need to be made in the nursing care plan？

如果患者的情况发生变化，护理计划需要做何修改？

The answers to these questions will help the nurses decide whether to continue or change the nursing care which the patient needs. Answering these questions can also help each nurse give the best nursing care as the nurse works with patients and moves through the steps in the nursing process.

回答这些问题将有助于护士决定是否延续或改变病人的护理需求，也会有助于护士在护理过程中给患者提供最好的护理。